A Final Arc of Sky

A Memoir of Critical Care

From an award-winning writer, a masterful reflection on the chaos of emergency medicine and the beautiful fragility of our lives

A critical care and emergency flight nurse, Jennifer Culkin is no stranger to death and its dramas, or the urgency that accompanies them. Her memoir plunges us into the chaos of emergency medicine at all altitudes, masterfully reflecting on the most pivotal moments of our lives and the beautiful fragility of our mortality.

“In this compelling memoir, her moving reflections on life and death interweave clinical encounters with her own life. . . . Culkin sees herself and others clearly, and poetic juxtapositions make her sentences soar.” —Publishers Weekly

“With its perfect capture of the fragility of life and our vulnerable human bodies and bonds, A Final Arc of Sky . . . is a disturbing, powerful read.” —Lynda V. Mapes, Seattle Times

“Rarely have we heard from such an eloquent yet urgent voice from the front lines of mortality. . . . Culkin writes with elegiac grace and unblinking honesty.” —Robin Hemley, author of Invented Eden

“Absorbing . . . This former neonatal and pediatric intensive-care nurse has vivid memories of the tiny patients whose lives were in her hands, and she writes of them with warmth and clarity. . . . Powerful and lucid . . . The risks of being an emergency flight nurse-night flights, bad weather, human error-come fully alive. . . . Enthralling.” —Kirkus Reviews

“With her electrifying scenes, her gorgeous sentences, and her provocative explorations of the borderland between life and death, Culkin engaged my heart, my intellect, my artistic sensibility, and my adrenaline.” —Ann Pancake, author of Strange as This Weather Has Been

“I loved the stories, the language, the point of view, but what I loved most was the way this book was able to break my heart—then mend it.” —Judith Kitchen, author of Distance and Direction

Chapter One: The Shadow We Cast

When I parked my car at ten minutes to nine that summer morning and dragged my helmet, flight bag, food, and laptop up the stairs at the southernmost of our four helicopter bases, the last dregs of predawn coolness still lingered in the air. I was in a good mood. I had just blasted the B-52’s Cosmic Thing on my car stereo, playing my favorite tracks over and over like a fiveyear- old for the hour and a half it had taken me to commute to the base from home for a twenty-four-hour shift. The National Weather Service had predicted temperatures in the nineties, but the heat hadn’t yet begun to shimmer off the helipad back behind the fire station where we were quartered.

The fire station is tucked into a rural corner of a mediumsized suburban city, next to a county airfield, and the landscape around it was cleared of its native forest a long time ago. It’s as open as farmland in Kansas, dotted with Scotch broom, an invasive weed that is nevertheless lush with tiny yellow blooms each May. The sweep of the earth falls away to volcanic mountains in the distance, still snow-covered even in summer, and on my speed walks around the fire station for exercise I’d come to love it, in spite of the landfill that’s practically next door. I loved the light and space, the foothill feeling of the land as it runs imperceptibly up toward the mountains.

The day felt pregnant, though--that occupational precognition I’ve come to trust and dread. It’s a feeling with a dart of fatalism in it, a blind, nonnegotiable foreknowledge, and I’ve learned the hard way that it’s pretty accurate. Not 100 percent infallible, but up there. Whenever the feeling comes on me, I think of the animals who head to high ground before a tsunami, whose nervous systems seem to warn them of earthquakes and floods. Rats deserting a sinking ship.

It was also a Friday in high summer, so no shit, Sherlock, of course we’d be busy. We could look forward to office workers ordering margaritas at outside tables in the hot afternoon and driving home wasted in the dusk. Guys with huge guts and crap in their coronary arteries pushing their lawn mowers in the heat around their acre-and-a-half yards. Stoic eighty-year-old Scandinavians deciding it was time to climb their twenty-foot ladders and clean the old moss off their roofs.

Jason was my partner. We chatted with the off-going crew, lingering over our coffee in the sturdy firehouse kitchen. Eventually we strolled out into the fine summer sunlight, across a short expanse of pavement, and under the main rotor to check the helicopter and our medical bags for completeness and readiness. Everything looked good. No blood splatters on anything, maybe just a couple of small things missing, and we replaced them. At the time, I had been a flight nurse for about three and a half years. Jason had just transferred from another base; I’d met him and talked to him at meetings, but we hadn’t flown together before. He was our youngest flight nurse, about fifteen years younger than me, which is to say he was fifteen years younger than most of us, a thing he was teased about occasionally. He was short and compact, bespectacled, analytical and smart, calm. We finished our checklists and went into the office to fax our supply requests to the main base.

Jason put his feet up on the desk and said it was almost a year to the day since he’d started with our outfit. “My first flight,” he said, chuckling, “was CPR in progress for thirty minutes in the aircraft.”

“Ouch! Was it trauma”

“Yup. A rollover on the freeway. It was . . . stressful.”

“Was CPR already in progress when you took over the care of the patient”

“Yup.”

“Hah! That is stressful, especially for a first flight,” I said, picturing it and laughing a little. On your first-ever flight, the rush of foreign sensations--the vibration, the roar, the cramped quarters, the whizzing landscape--makes the simple act of strapping yourself in to the helicopter enough of a challenge.

“But to my mind it’s not the most stressful situation,” I added. “I mean, when you get trauma patients with CPR in progress, yes, it’s an exercise in doing everything possible, but they’re basically dead already. You can’t hurt v´em.” At that point, I was thinking of a physician friend, my own gastroenterologist. I see him for gastroesophageal reflux-- chronic heartburn, and who knows whether it’s because of genetics, the two ten-pound babies I’ve borne that mashed my insides to a pulp, or this job. He told me once that when he’d first started out in medicine, he was scared to take care of really sick--critical--patients.

“But then I realized,” he’d confided, grinning a little, “that they only get so sick, and then they die.”

Yeah.

“The most stressful situation,” I mused aloud to Jason, “is when they’re lying there talking to you and then they code. The ones who roll back their eyes and die right there.” I can’t remember if I mentioned to Jason that it was a situation that had never yet happened to me in flight, but it hadn’t. And for all my years of experience on the ground and in the air, I didn’t know how well I would acquit myself if it did. I must have temporarily lost my mind, saying such a thing with that fatalism sitting like a stone in my stomach, with the twenty-four-hour day so early in gestation and our flight suits so clean, with the caffeine of the morning coffee still running in our veins. Saying such a thing on a Friday in summer. Jason snorted. The harsh fluorescent light on the office ceiling flashed off his stylish little glasses, and I couldn’t tell what he was thinking. It was probably something like Now she’s cooked our goose. “Well, yeah,” he said. “No question about it. That would be the worst.”

It was early afternoon when the pager shrieked for the first flight of the day. We kicked off our sandals and zipped up our boots and our flight suits, and off we went to a small community hospital, a thirty-minute flight toward the coast, over open valleys and rivers winking like bottle caps in the hot noonday sun. Brad, our pilot, dropped the aircraft down light and easy onto the helipad, and Jason and I slid our stretcher, bags, and monitor out onto a gurney. We trucked the whole thing in through the emergency department door and up to the ICU on the second floor.

Our patient was Doug. He was forty-six years old, with esophageal cancer and an upper gastrointestinal hemorrhage, and we were transporting him to an oncology referral center, where they had more resources to deal with his problems. His esophagus, which transports food from the mouth to the stomach, had a large tumor on it, and he had been receiving chemotherapy and radiation to debulk it, to shrink it enough so that a surgeon would have a shot at removing it. Apparently, a blood vessel in that region had eroded earlier that morning. It had gouted large amounts of blood.

A hematocrit measures the percentage of the volume of red blood cells in the total volume of blood and is used as quick guide to how much blood has been lost and how well it’s being replaced. A normal crit is about 40 percent. After he started vomiting blood, Doug had an initial crit of 17 percent. He had received five units of packed red blood cells and other blood products since that measurement had been taken, but there hadn’t been a repeat crit. He had not vomited any blood recently, and he came with a tube that had been surgically placed in his stomach through his abdominal wall--there wasn’t much output from that, either. We could assume that the bleeding vessel had clotted off. For the moment. He had other problems too. A collection of straw-colored fluid between his left lung and the pleura, the covering around his lung: a pleural effusion caused by impaired lymphatic drainage secondary to his tumor. The ICU staff had just drained 520cc--more than two cups, quite a bit. I hoped it wouldn’t reaccumulate too quickly. He also had a small pneumothorax of the right lung. This was a collection of air between the pleura and the lung. The problem for us was Boyle’s law: air expands at altitude, and aloft a small pneumothorax can become a large pneumothorax, collapsing the lung and, if it’s big enough, compressing the heart and the great vessels that transport blood into and out of the heart. In an ICU, a big pneumo would buy the patient a chest tube so air could drain continuously. At altitude, if it became a problem, Jason and I would temporarily treat the pneumo with a flutter valve--a large-bore, sharp steel needle that had been sterilized with a disposable-glove finger rubber-banded to the hub. The glove finger acts as a one-way valve. We’d stick the needle through his chest wall, into the space between the second and third rib, and it would allow air to escape.